Healthcare Provider Details

I. General information

NPI: 1225701550
Provider Name (Legal Business Name): PENSACOLA PEDIATRICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5755 QUINTETTE RD
PACE FL
32571-9711
US

IV. Provider business mailing address

4951 GRANDE DR
PENSACOLA FL
32504-8965
US

V. Phone/Fax

Practice location:
  • Phone: 850-995-8087
  • Fax: 850-994-5292
Mailing address:
  • Phone: 850-473-0100
  • Fax: 850-473-0500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier063018703
Identifier TypeMEDICAID
Identifier StateFL
Identifier IssuerFlorida Medicaid Provider ID

VIII. Authorized Official

Name: PETER HECKATHORN
Title or Position: ADMINISTRATOR
Credential:
Phone: 850-473-0100